The Department of Defense (DoD) Pharmacoeconomic Center is a hive of buzzing activity and a melting pot of various health care personnel from the U.S. Army, U.S. Navy, U.S. Air Force, U.S. Public Health Service, DoD civil servants, and private contractors. Located in San Antonio and operating within the Military Health System, pharmacists at the center, affectionately dubbed the PEC, manage numerous facets of a world-class pharmacy benefit program. From helping deployed patients in remote locations, to analyzing a wealth of pharmacy and medication data, to overseeing a standardized formulary that stretches across three points of care, the PEC is a diverse environment for pharmacy practice.
As part of TRICARE, the uniformed services health care program for active duty service members, their families, and other eligible individuals, “we are in charge of implementing and maintaining the pharmacy benefit for the DoD’s beneficiaries,” said CDR Joseph B. Lawrence, PharmD, MBA, BCPS, FAPhA, MSC, USN. “While we are not actually a pharmacy, we often have a significant role in interacting with numerous health care providers, beneficiaries, and dispensing pharmacies throughout the world.”
As the Director of the PEC, Lawrence oversees the direct operational support for all DoD pharmacy points of service, including a mail-service pharmacy, 57,000 community pharmacies, and 600 pharmacies located at military treatment facilities. With 19 pharmacists, 12 pharmacy technicians, 3 physicians, and a handful of other individuals who work in data analysis and information technology or database management, “there are a lot of different layers here,” explained Lawrence. “We have pharmacists conducting literature reviews or cost effectiveness studies, working on data synthesis, interacting with the TRICARE pharmacy benefit manager and military treatment facilities, and answering questions arising from the Pentagon, White House, or Capitol Hill. It can be pretty exciting.”
Lawrence visits Express Scripts Inc., TRICARE's contracted mail-service pharmacy in Tempe, AZ.
The DoD pharmacy benefit includes 9.7 million people including active duty service members and their families, retired service members and their families, members of the National Guard/Reserve and their families, survivors, and other eligible beneficiaries. Around 100 million prescriptions are dispensed every year through the three points of service—military pharmacies, community pharmacies, and mail service.
According to Lawrence, the pharmacists’ responsibilities boil down to the following four primary areas:
According to Lawrence, the lion’s share of the work at the PEC is focused on clinical and cost effectiveness reviews. “This interdisciplinary team pulls together literature and data and reaches out to practicing pharmacists and physicians to develop quality recommendations that we can present to the P&T Committee,” Lawrence said in an interview with Pharmacy Today. This group also conducts a thorough review of the budget impact and pharmacy utilization.
The pharmacy outcomes research team, which was established in 2008, collaborates with organizations such as DoD quality management agencies and academic institutions to conduct detailed studies “that are focused on outcomes of drug therapy to make sure our pharmacy benefit is as robust and effective as possible,” explained Lawrence. For example, if the P&T Committee makes a change to the formulary, the team studies how both the beneficiary as well as the health care team might be affected. “We make sure that we are getting the clinical outcomes that we desire when making these changes,” said Lawrence. “By studying the data and finding trends in prescribing patterns and medication selection, we can develop explanations for what is going on so we can speak to how well we are performing.”
A notable aspect of the PEC is that the formulary for all three points of service is published in a variety of formats. “We are very proud of the whole idea of transparency,” Lawrence explained. “Most pharmacy plans don’t spend a lot of effort explaining how they derived their formulary decisions or seeking beneficiary input in the process.”
Another feature that sets the PEC apart is the Beneficiary Advisory Panel. “We are the only group that I know of in the private or government sectors that, prior to enacting any changes to the benefit, opens it up to [the] public,” said Lawrence. The P&T Committee shares any changes to the formulary in a public forum. The panel reviews the proposed changes, makes a recommendation, and combined with public comment, the information is “packaged together” for approval and implementation, noted Lawrence.
A unique program within the PEC is the Pharmacy Data Transaction Service (PDTS), a centralized prescription data repository that creates a single, comprehensive patient drug profile for DoD beneficiaries across the entire system. PDTS enables the DoD to perform prospective drug utilization review across the patient’s profile to screen for drug interactions no matter where the DoD beneficiaries filled their prescriptions. Pooling this data into one resource has allowed us “to create homegrown tools” to slice, dice, and monitor patient information. For example, Lawrence and his team developed a prospective drug screening tool. “If a patient receives a prescription from the mail, and [a prescription] from a treatment facility and there is a drug interaction or overutilization concern, then it could be screened in real time,” he said.
Lawrence (center) and a team of pharmacists maintain the pharmacy benefit for the DoD.
The group also developed a tool that can be used in the theater overseas to help troops manage medications. A clinical pharmacist or other health care provider who is deploying with a troop unit can upload all the medication profiles for each person in the unit and have a comprehensive snapshot of all the medications. “This [tool] allows them to [identify] patients that might need monitoring out in the field or patients who have medications that may be problematic in a deployment area. Some medications have limited distribution or require special shipping,” said Lawrence.
The database also provides support for caring for wounded active duty troops with long-term medical and rehabilitation needs. “Typically these patients are seen by multiple providers and are moving around in multiple states,” said Lawrence. “We use this tool to make sure providers have a comprehensive patient profile at their fingertips.”
In addition, there are tools to monitor controlled drugs. “In some cases a patient may have drug-seeking behavior, so we built tools to allow providers to identify patients who are seeking multiple prescriptions for controlled drugs at multiple pharmacies from multiple physicians,” explained Lawrence.
One of the most interesting programs is in the deployment prescription arena. If a clinical question comes up and a pharmacist needs to intervene, it can be challenging when the patient is deployed in a remote location. Pharmacists at the PEC take calls from all over the world and play a critical role in coordinating care and resolving clinical issues.
Although interacting with patients isn’t a large component of the services provided by the PEC, “when we do interact with patients we have a lot of success stories. If we didn’t intervene, then the patient would be without their medications or there would be a delay in the patient getting their medications,” said Lawrence.
The PEC is also involved in making sure the plan’s beneficiaries receive their medications in disaster situations. After the tsunami in Japan, many of the plan’s patients were evacuated with very little time to prepare or pack. “When you have to leave that quickly, you don’t have your medications with you,” Lawrence explained. “We got involved and from here at the PEC we could see what prescriptions they were on and coordinate care to make sure they got their medications.”
Lawrence tours Express Scripts Inc.'s mail-service fulfillment center.
In the aftermath of Hurricane Katrina, a large number of patients had to be evacuated and pharmacy records were lost. “We were able to pull the information from our database and communicate with pharmacists and physicians to make sure patients got back on track with their medications as soon as possible,” said Lawrence.
The PEC offers limited medication therapy management (MTM) services through the mail-order pharmacy for specialty drugs. MTM discussions are “more in the policy world right now in deciding how we should cover it, what services we want to offer, and how do you know if the service you offer is effective,” said Lawrence. Many of the military treatment facilities, as part of the Military Health System, offer MTM services, and “we are already working with them to assess those programs and see where we can copy their successes and make them more effective,” said Lawrence. He believes that MTM is something that the profession as the whole is still struggling with. “We are certainly looking at it and trying to decide for ourselves where it fits into the bigger picture of our benefit,” he added.
From making formulary recommendations to resolving medication challenges for troops in the theater, the PEC is the most unique practice setting Lawrence has ever encountered during his 19-year career in the Navy. One of the most significant things about the PEC, he noted, is that it’s not a pharmacy, yet “we are completely dedicated [to our patients] and without a doubt, my colleagues are the most qualified and highly respected pharmacists I’ve ever known.”